PURPOSE:

To implement a consistent CQI program that complies with California State law and regulations and to improve EMS delivery within the region.

AUTHORITY:

California Health and Safety Code, Division 2.5, Sections 1797.204, 1797.220, 1798 and 1798.102.

California Code of Regulations, Title 22, Sections 100146, 100167, 100168, 100169, 100170 and 100171.

POLICY:

The S-SV EMS system shall strive to provide the highest level of customer service at all times. All processes and procedures should be evaluated for improvement possibilities.

PROCEDURE:

All CQI records shall be maintained for a period of 2 years.

1. Service Provider
   
   The ALS service provider shall designate a continuous quality improvement (CQI) coordinator. The designated CQI coordinator shall be a Registered Nurse or EMT-Paramedic.
   
   A panel of non-management field personnel shall be designated to participate in the review of Patient Care Reports (PCR) for their service provider agency. The service provider's CQI coordinator or designee should act as a facilitator to this peer panel. The selected peer panel shall review the following:
   
   
   1. Critical cases in which the following interventions were indicated:
      
      
      1. Oral intubation
         
         
      2. Nasal intubation
         
         
      3. Combitube
         
         
      4. Needle cricothyrotomy
         
         
      5. Needle chest decompression
         
         
      6. Intraosseous access/infusion
         
         
      7. Administration of rectal Diazepam (Valium)
         
         
      8. Medical use of helicopter
         
         
      9. Multi-Casualty Incidents
         
         
      10. Minors released at scene
          
          
   2. Focused audits on a regular basis to include:
      
      
      1. Destination other than the closest
         
         
      2. % of PCRs left with patients at receiving hospital
         
         
      3. Data form accuracy
         
         
   3. Committee requirements:
      
      In addition to any specific requirements instituted by a provider agency, the Committee shall identify trends associated with the delivery of care. These trends shall be reported to the S-SV EMS Agency for evaluation. It is the responsibility of the CQI Coordinator(s) to attend and participate in Regional Committee meetings.
      
      
2. Base/Modified Base Hospital(s) CQI Committee
   
   
   1. The base/modified base hospital CQI Committee shall meet the following minimum requirements:
      
      
      1. Be chaired by a base/modified base hospital physician.
         
         
      2. All participants shall sign a binding confidentiality statement.
         
         
      3. Meet on a regular basis, at least quarterly.
         
         
   2. This committee shall review:
      
      
      1. All needle cricothyrotomies.
         
         
      2. All needle pleural decompressions.
         
         
      3. All optional skills utilized by EMT-Ps
         
         
      4. All cases referred by service provider panel.
         
         
      5. Focused audits on a regular basis (example: asthma or chest pain cases).
         
         
   3. Committee requirements:
      
      In addition to any specific requirements instituted by the base hospital, the Committee shall identify trends associated with the delivery of care. These trends shall be reported to the S-SV EMS Agency for evaluation. It is the responsibility of the CQI Coordinator(s) to attend and participate in Regional Committee meetings.
      
      
3. Receiving Hospitals within S-SV EMS Region
   
   All receiving hospitals within the S-SV EMS Region will submit data on EMS patients with diagnosis codes pertaining to spinal injury, when requested by the S-SV EMS Agency.
   
   
4. Transferring Hospitals
   
   Transferring Hospitals within S-SV utilizing EMT-Ps to monitor nitroglycerine and/or heparin during interfacility transfers will audit 100% of these calls.
   
   
5. S-SV EMS Agency
   
   The focus of all Continuous Quality Improvement Program activities shall be on system improvement, not on an individual's performance. Performance problems are to be identified by each service provider agency and corrected. Potential or questionable violations of Health and Safety Code, Section 1798.200, shall be reported to the S-SV EMS Agency. These issues will be handled separately from the Committee activities, in accordance with state law, regulations and local policy.
   
   The purpose of the S-SV EMS Agency Regional Medical Control Committee includes: (1) the provision to function as advisory to the S-SV EMS Agency; and (2) to represent the position of base hospitals and ALS service provider agencies in prehospital care and emergency medical services issues.///Continuous Quality Improvement items shall be added to the Medical Control Committee meeting agenda. This committee shall:
   
   
   1. Review statistical information. System-wide statistics can be evaluated for local and/or regional trends.
      
      
   2. Review Provider and base/modified base hospital focused audits.
      
      
   3. Develop ongoing system-wide criteria for screening and trend identification.
      
      

CROSS REFERENCES

Policy and Procedure Manual